Bates’ Visual Guide to Physical Examination

6.4 Examining the Skin Video Transcript

Narrator: With the patient’s health history in mind, and after good hand hygiene, you are ready for the physical examination.

For a thorough skin examination, make sure the patient wears a gown that allows close inspection of the anterior and posterior body surfaces, the hair and feet and hands. Inspect and palpate the skin, noting its color, moisture, temperature, texture, mobility and turgor and any lesions.

Doctor: Have you noticed any changes in any pigmentation of your skin?

Narrator: A patient may notice changes in skin color before you do. Ask if the patient has noticed any such changes; specifically, increased pigmentation, most often increasing brownness, or loss of pigmentation, redness, pallor, cyanosis or yellowing of the skin. The red color of oxyhemoglobin and the power resulting from a lack of it are best assessed where the horny layer of the epidermis is finished and causes the least scatter at the fingernails, lips and mucous membranes, particularly those of the mouth and palpebral conjunctiva. In dark-skinned persons, inspecting the palms and soles may also be useful.

Central cyanosis is best identified in the lips, oral mucosa and tongue. The lips can also turn blue and the cold and melanin in the lips may stimulate cyanosis in darker skinned people. Cyanosis of the nails, hands and feet may be central or peripheral in origin. Anxiety or a cold examining room may cause peripheral cyanosis.

Look for the yellow color of jaundice in the sclera. Jaundice suggests liver disease or excessive hemolysis of red blood cells. Jaundice may also appear in the palpebral conjunctiva, lips, hard palate, under surface of the tongue, tympanic membrane and skin.

To see jaundice more easily in the lips, blanch out the red color by pressure with a glass slide. Here, jaundice is not present. For the yellow color that accompanies high levels of carotene, look at the palms, soles and face.

Assess for moisture, noting characteristics such as dryness, sweating and oiliness. When assessing for skin temperature, use the backs of your fingers. Carefully note the temperature of any red areas. Characteristics of texture include roughness and smoothness.

To assess mobility, lift a fold of skin and note the ease with which it lifts up. To assess turgor, note the speed with which the skin returns into place.

Observe any lesions of the skin, noting they are important characteristics. Note the anatomic location and distribution of any lesions over the body. Do they involve exposed surfaces, the intertriginous or skinfold areas, extensor or flexor areas, or acral areas such as the hands and feet. Do they involve any areas exposed to specific allergens or irritants such as wristbands or rings?

Describe the type of lesion. Is it a macule or flat-on-skin surface like a café au lait spot. Is it raised or a papule seen in psoriasis. Is it a vesicle that is palpable and fluid-filled or a nevus or pigmented lesion. If possible, find and inspect representative and recent lesions that have not been traumatized by scratching or otherwise altered. Note their patterns and shapes. Are the lesions linear, clustered, annular; that is, in a ring, arciform; that is, in an arc, or dermatomal meaning covering a skin band that corresponds to a sensory nerve root. Finally, note the color of the lesions.

When examining nevi, apply the ABCDE method for assessing melanomas. Inspect for asymmetry, irregular borders, color variation especially blue or black mixed with white and red, diameter larger than 6 mm and evolution or change in size, symptoms or morphology. Also learn to recognized the raised, pearly sometimes reddish lesions of basal cell carcinomas and the roughened, hyperkeratotic flaking reddish lesions of squamous cell carcinomas. These carcinomas are often in sun exposed areas.

Reference a well-illustrated textbook of dermatology or online source so that you can broaden your knowledge of skin disorders and related systemic diseases. Accurate description of lesions and their location and distribution combined with a history and overall physical examination will gradually build your clinical acumen.

Doctor: Look at the back of your leg and see if you can see some of the areas you are concerned about.

Narrator: Teach the patient the best techniques for self-examination of the skin as recommended by the American Academy of Dermatology.